- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.76 / $1,425.54 / $1,920.94
| Facility | | $508.76 | $1,425.54 | $1,920.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $508.76
| Professional | | $508.76 | $508.76 | $508.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.50 / $740.44 / $1,252.01
| Professional | | $505.50 | $740.44 | $1,252.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $479.96 / $479.96 / $508.76
| Facility | | $479.96 | $479.96 | $508.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.45 / $432.45 / $508.76
| Professional | | $432.45 | $432.45 | $508.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.97 / $508.76 / $824.59
| Professional | | $462.97 | $508.76 | $824.59 |